Understanding When Aspirin Helps in Type 2 Diabetes
New observational data suggest selected people with type 2 diabetes could see cardiovascular benefit from primary prevention aspirin when bleeding risk is low.
A large real world analysis presented at AHA 2025 suggests that adults with type 2 diabetes at moderate to high cardiovascular risk may experience fewer heart attacks, strokes, and deaths with low dose aspirin use, challenging the idea that primary prevention aspirin is always inappropriate.
Study Details
For the past decade, guidelines have steadily moved away from recommending aspirin for primary prevention of cardiovascular disease because bleeding risks often outweigh modest benefits. This shift was driven by major trials like ASPREE, which showed increased gastrointestinal bleeding in older adults without clear survival benefit.
However, people with type 2 diabetes represent a biologically distinct group. Diabetes is associated with higher platelet activity, chronic inflammation, and accelerated atherosclerosis. Investigators from the University of Pittsburgh Medical Center examined whether aspirin’s risk benefit balance might look different in this population.
Their findings were presented during a poster session at the American Heart Association annual meeting in New Orleans.
Methodology
Researchers analyzed electronic health record data from a primary prevention registry that included adults without known cardiovascular disease at baseline. The study focused on individuals with type 2 diabetes who were at intermediate or high risk for ASCVD but not at high risk of bleeding.
Key design features included a 10 year follow up period, propensity matched comparisons between aspirin users and nonusers, and stratification by adherence to low dose aspirin therapy. Bleeding outcomes were not captured, and individuals with conditions that increase bleeding risk were excluded.
The final cohort included more than 11,600 adults with a mean age of about 62 years.
Key Findings
Lower rates of myocardial infarction or revascularization were observed among aspirin users compared with nonusers
Ischemic stroke occurred less frequently in those taking aspirin
All cause mortality was lower in aspirin users over 10 years
Higher adherence to aspirin therapy correlated with greater cardiovascular protection
Benefits persisted across HbA1c levels and risk strata
Strong associations were seen even with intermittent use, with the largest effects among those using aspirin at least 70 percent of the time
Implications for Practice
For patients with type 2 diabetes, this study reopens a nuanced conversation about aspirin. Rather than a blanket recommendation or prohibition, aspirin may still have a role for carefully selected individuals who have elevated cardiovascular risk and low bleeding risk.
For clinicians, these findings highlight the importance of individualized risk assessment. Factors such as age, gastrointestinal history, concurrent anticoagulant use, kidney disease, and overall inflammatory burden remain critical. The absence of bleeding data is a key limitation and underscores why aspirin decisions must remain personalized.
For patients, this study reinforces that aspirin should not be started independently. The potential benefit appears meaningful in some people with diabetes, but only when weighed carefully against bleeding risk in partnership with a healthcare professional.
Future research will explore how aspirin interacts with statin therapy, GLP 1 medications, and newer lipid lowering agents, which may further refine who stands to benefit most.